Registration & Health Declaration

(PAR-Q) Form

Before you begin one of our exercise or dance classes the instructor needs to know some information about you to ensure the exercises are safe and effective.

If you are between 15-69 years of age this PAR Q checklist will assist you in making a decision about your state of health before you change or increase your physical activity behaviour.

If you are over 69 years of age and not already participating in regular exercise it is advisable to check with your doctor before you begin.

First Name

Last name

Address

Date of birth

Day

Month

Year

Phone

Email

Emergency Contact Name

Emergency Contact Phone Number.

Please answer each question honestly with YES or NO

Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?

Yes

No

Do you feel pain in your chest when you do physical activity?

Yes

No

In the past month, have you had chest pain when you were not doing physical activity?

Yes

No

Do you lose your balance because of dizziness or do you ever lose consciousness?

Yes

No

Do you have a bone or joint problem (e.g., back, knee or hip) that could be made worse by a change in your physical activity?

Yes

No

Is your doctor currently prescribing any medication for your blood pressure or heart condition?

Yes

No

Have you had an operation in the last 6 weeks?

Yes

No

Are you currently, or have you been pregnant in the last six months?

Yes

No

Do you have any other medical conditions/injuries/strains or know of any other reason why you should not participate in physical activity? If yes, please explain…

If you answered YES to one or more of the questions above we recommend you should consult your doctor to gain consent before participating in physical activity.

YES but I have sought advice from a medical professional who has approved me safe to exercise.

NO to all the questions above. It is considered reasonably safe for you to participate in regular physical activity.

It is recommended that you start slowly – 20-30 minutes of low to moderate exercise, 3-5 times per week – and gradually

build up from your current ability level.

Emergency Medical Treatment - I consent to any medical treatment in the event of an accident if I am unconscious or unable to respond:

Yes

No

Media - The company may take photographs and film sessions for advertising/publicity material and also to be used on our website/social media pages. I allow myself to be included in this.

Yes

No

I would like to subscribe to receive email updates from WorkitOut Studios.

Yes

No

I have read and understood the questions above and any questions I had have been answered to my satisfaction. I understand that I am voluntarily engaging in a level of exercise appropriate for my

ability and that my participation involves a risk of injury.

I declare that the information I have provided is accurate and complete.

Signature

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Date